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QUESTION: A 3 yo male presents at 2am with a barking cough. He has been sick for 2 days with cough, rhinnorhea and mild fever. Parents say that when he was running around the waiting room he was making an audible noise. Currently he is sitting quietly in his parents arms. Exam is remarkable only for mild tachypnea. What is the best treatment for this patient?a. Decadron onlyb. Nebulized Epinephrine onlyc. Albuterol onlyd. Decadron and Nebulized Epinephrinee. Decadron and Albuterol

ANSWER:

a. Decadron onlyThis patient has croup. Croup most commonly occurs in children 6m – 6 yo and often is worse at night. This patient has stridor with activity (in waiting room while running) but no stridor at rest. The lack of lower airway sounds help rule out the diagnosis of asthma or bronchiolitis. The treatment for croup with NO stridor at rest is decadron only. If stridor at rest had been present, the treatment would be decadron PLUS nebulized epinephrine. Albuterol is not indicated for croup.

PEARL: Stridor at rest = Decadron + Nebulized EpinephrineNo stridor at rest = Decadron onlyARTICLE:Sparrow A and Geelhoed G. Prednisolone versus dexamethasone in croup: a randomized equivalence trial. Arch Dis Child. 2006;91(7):580.BACKGROUND: Croup remains a common respiratory problem presenting to emergency departments. A single oral treatment of oral dexamethasone results in improved outcome. Prednisolone has similar pharmacokinetic properties and has a significant advantage in that it is commercially available in liquid preparations.OBJECTIVE: To ascertain whether a single oral dose of prednisolone was equivalent to a single oral dose of dexamethasone (matched for potency) in children with mild to moderate croup.DESIGN: A double blind, randomised, controlled equivalence trial.SETTING: Tertiary paediatric emergency department. Patients: 133 children aged 3 to 142 months presenting with mild to moderate croup.INTERVENTIONS: Children received either a single oral dose of dexamethasone 0.15 mg/kg or single oral dose of prednisolone 1 mg/kg. Outcome: The main outcome measure was unscheduled re-presentation to medical care asdetermined by telephone follow up at 7 to 10 days. Croup score, adrenaline (epinephrine) use, time spent in the emergency department, and duration of croup and viral symptoms were secondary outcome measures.RESULTS: Children treated with prednisolone were more likely to re-present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures.CONCLUSION: A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re-presentation to medical care in children with mild to moderate croup

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